Approach to the management of pneumonia with a moderate or large parapneumonic effusion in children

CT: computed tomography; IV: intravenous; VATS: video-assisted thoracoscopic surgery.
* A small effusion is defined as <1 cm on a lateral decubitus radiograph or one that opacifies less than one-fourth of the hemithorax^[1].
¶ Ultrasonography is generally preferred over CT for evaluation and monitoring of pleural effusions. CT should be reserved for complicated cases in which further characterization of parenchymal disease is needed or ultrasonography is inadequate^[2].
Δ An alternative to chest tube placement for patients who are clinically stable is a trial of empirically selected IV antibiotics for 24 to 72 hours.
◊ Whenever thoracentesis or drainage is performed, the fluid should be cultured and IV antibiotics started; the choice of antibiotics should be reevaluated depending on culture results.
§ If a chest tube is placed, small-bore tubes (<14F) should be used when possible, even for loculated effusions. Small-bore chest tubes are effective with fibrinolytics and cause less discomfort to the patient^[2].
¥ For initial treatment of a complicated effusion, most experts agree that either pleural drainage with fibrinolytics or VATS is a reasonable first step. The choice may be influenced by available expertise, cost considerations, and patient preferences.
‡ Patients who fail to improve after VATS may require open thoracotomy to remove the pleural rind and evacuate pyogenic material ("decortication").
† Antibiotics may be changed from IV to oral route when the child has been afebrile for 2 to 5 days.